Sample Nursing Paper on Nurse Practitioner SOAP Note

Nurse Practitioner SOAP Note

Subjective

ID: AP, 05/02/1970, age 52, Latino, Female, Patient was alone and was a reliable source and able to answer for herself. The patient lives at home and has a husband and two sons.

 

CC: ‘I am feeling a burning sensation and tingling on the left side of my body

HPI: 52-year-old female, Latino, is here for a regular checkup. She presented with a 4-week history of a painful rash on the left side of her body. She reports that the rash started as small spots and has since grown in size and spread. She also reports experiencing localized burning pain in the affected location. Aggravating factors are ongoing high-stress levels and the presence of recent trauma to the skin. She states that over-the-counter medications have not been providing her with adequate relief and that her symptoms seem to be worsening.

 

 

PMH

Medical Problem list: Fever, Fatigue

Surgeries and hospitalizations: None

Immunizations: Up to date with the current age

Allergies: Latex, Codeine, Aspirin

Medications: Over-the-counter drugs

Family History: Father; Stroke, Mother; Heart disease

Chemicals: None

Exercise/Exercise: practices yoga

Sexual/Reproductive History: Has a husband and two sons

Social History

Occupational marital & current living situation: Has two sons, as well as a husband.

Spiritual/Social Supports: Catholic

Review of Systems

  • General Survey: The patient states experiencing fever, headache, and fatigue
  • Eyes: Patient states blurred vision in the evenings
  • Ears/Nose/Mouth/Throat: Patient denies any feeling of pain
  • Cardiovascular: Patient denies chest pain, and heart palpitation.
  • Pulmonary: Patient denies respiratory issues like shortness of breath or wheezing.
  • Gastrointestinal- The patient denies a history of any abdominal or stool issues and denies any abdominal discomfort.
  • Genitourinary: Patient denies constipation, and diarrhea and has no history of any issues
  • Musculoskeletal: Patient denies range of motion issues
  • Integumentary & breast: Patient states feeling bumps on her lymph nodes
  • Neurological: Patient denies any issues of memory and is oriented to person, place, time, and situation.
  • Psychiatric: Patient denies any history of depression or anxiety and is happy and not distressed
  • Endocrine: Patient denies any diabetes or thyroid issues
  • Hematologic/Lymphatic: Patient denies any issues
  • Allergic/Immunologic: Patient states she is allergic to Latex, Codeine, and aspirin.

 

Objective

Physical Exam

Vital Signs: BP: 120/80, HR: 96, RR: 16, O2: 100%, Weight: 150Lbs, Height: 5’4, BMI 23.4

Physical

General Survey: The patient is alert, and nicely dressed, but shows signs of stress

Eyes: Visual acuity 20/20 OU, Normal size and reactive OU

Ears/Nose/Mouth/Throat: The patient’s ears, nose, mouth, and throat were all clear

Cardiovascular: Heart rate was 72 beats per minute and regular, with no murmurs or extra heart sounds. Blood pressure was 120/80 mmHg and pulses were normal in all four extremities. No edema present.

Pulmonary: Lungs were clear to auscultation bilaterally with no wheezing, crackles, or rhonchi. Cardiac examination revealed regular rate and rhythm and normal S1 and S2 without murmurs, rubs, or gallops. The abdomen was soft, non-tender, and without organomegaly.

Gastrointestinal: The patient presented with mild epigastric tenderness and mild abdominal distension. No hepatosplenomegaly or masses were noted. No organomegaly was noted. Bowel sounds were regular and audible. No abdominal tenderness or guarding was noted. No evidence of shingles in the abdominal region was observed.

Genitourinary: palpated bladder and percussed no issues found

Musculoskeletal: The patient was able to perform the full range of motion with no issues. Integumentary & breast: Skin is clear, with no signs of edema or trauma. Skin is not discolored, no swollen lymph nodes, masses, or rash.

Neurological: Patient-oriented to person, place, time, and situation

Psychiatric: The patient appears to be in good mental health

Endocrine: Thyroid-stimulating hormone (TSH)-within normal range

Hematologic/Lymphatic: Patient CBC looks within a healthy range.

Allergic/Immunologic: Vesicular rash consistent with shingles

Assessment:

Differential Diagnosis

1 H55.1 Varicella-Zoster Virus (VZV) infection, due to the presence of a vesicular rash and accompanying pain, as well as the patient’s history of chickenpox (Chang & Khan, 2021).

  1. H57.2Herpes Simplex Virus (HSV) infection due to the patient presents with classic symptoms of herpes zoster(shingles) including unilateral vesicular rash, pruritus, and pain (Gómez-Gutiérrez et al., 2022).
  2. H58.3 Acute viral exanthema due to erythematous, vesicular rash present on the left side of the torso (Xie et al., 2020).

 Diagnosis: H57.2Herpes Simplex Virus (HSV) infection due to the patient presents with classic symptoms of herpes zoster (shingles) including unilateral vesicular rash, pruritus, and pain

 

Plan:

Prescribe an antiviral medication (acyclovir) 500mg every 6 hours to reduce the severity and duration of symptoms. Advise patient to keep rash covered and clean to reduce risk of transmission to others. Educate the patient on proper hygiene and skin care. Recommend patient take over-the-counter pain medications (e.g. ibuprofen, acetaminophen) for pain relief. 5. Follow-up with the patient in 1-2 weeks for reassessment.

 

 

 

References

 

Xie, G., Wei, Q., Guo, W., Li, D., Sun, P., Wang, J., & Liu, H. (2020). An adult co-presented with varicella and herpes zoster caused by varicella zoster virus genotype J, China: a case report. BMC Infectious Diseases20(1). https://doi.org/10.1186/s12879-020-05192-3

‌Gómez-Gutiérrez, A. K., Flores-Camargo, A. A., Casillas Fikentscher, A., & Luna-Ceron, E. (2022). Primary Varicella or Herpes Zoster? An Educational Case Report From the Primary Care Clinic. Cureus. https://doi.org/10.7759/cureus.23732

‌ Chang, C., & Khan, A. (2021, May 14). A 3-week-old girl with the vesicular rash. Contemporary PEDS Journal; Contemporary Pediatrics. https://www.contemporarypediatrics.com/view/a-3-week-old-girl-with-vesicular-rash